Diagnostic Delimitation Problem

9. The delimitation problem, taken up in [Section A], is not identical with the differentiation problem, taken up especially in [Section C] but passim in Sections [B] and [D]; by delimitation we may refer to the process of localizing the diagnostic battle through exclusion of the other great groups of mental diseases that à priori ought not to come in question, but do come in question sometimes, before we slice down to the question.

10. Is there or is there not evidence of destructive lesion in the nervous system of this so-called Shell-shocker? Is this man a victim of organic or of functional neurosis? This latter is what may be termed the differentiation problem.

Confining ourselves now to the delimitation problem, what are the major groups of mental diseases that might come in question?

I shall enumerate these. We think of mental diseases as I, syphilitic; II, hypophrenic (that is, feeble-minded in some of its phases, including even slight degrees of subnormality not entitled to be called feeble-minded in the ordinary sense); III, epileptic; IV, alcoholic (or due perhaps to some drug or poison); V, encephalopathic (in the sense of some focal brain disease); VI, symptomatic (in the sense of some somatic disease); VII, senile (or presenile). The seven groups so far enumerated, I believe, the general profession is pretty well equipped to consider, at least roughly to diagnosticate and to handle with due respect to the interests of the patient and of the community. I am bound to say that some of my colleagues would not go so far as to the competence of physicians in general in these fields, and one is aware that a plenty of mistakes have occurred even in these groups through the bad judgment of practitioners. Nevertheless, I hold to the conception that our profession is reasonably well equipped to handle these greater groups, having in mind all the while the appropriate temporary calling-in of the specialist. But there are two more groups, in addition to these seven, in which I am not so sure that the general profession knows as much as it should. I refer to VIII, the schizophrenic group, commonly known as the dementia praecox group; and IX, the cyclothymic group, sometimes termed the manic-depressive group. It is the victims of the diseases that constitute these latter groups that ought unconditionally to be excluded with few exceptions from the army; and it is the study of these conditions which ought to be carried out as a part of every man’s post-graduate training, not merely for his work on draft boards, but for his work in civilian and reconstruction practice. There is another group of, X, psychoneuroses, with which the profession regards itself as familiar, and with which it doubtless is familiar, in what might be called blooming examples of hysteria, neurasthenia, and psychasthenia. But the nub of the situation lies in the fact that the diagnosis of instances which are not such blooming examples is difficult, and hence it was that I qualified my statement as to the competence of the practitioner in this tenth group. It is, of course, the tenth group, of psychoneuroses, into which the majority of the Shell-shock cases fall.

11. Now a study of the literature of the belligerents having Shell-shock in mind as its special topic and aim proves to require a study of war literature in all of these groups. There are cases of so-called Shell-shock which even well-prepared medical men have placed in the neurosis group, when they should have been placed in one or other of the groups mentioned.

12. In short, whereas the Shell-shock delimitation problem deals with groups, I, II, III, IV, VI, VIII, IX and (as our compilation shows) especially with groups I, III and VI, on the other hand the shell-shock differentiation problem deals primarily with groups V and X.

To clear the decks for action re the differentiation problem, let us dismiss the major troubles of the delimitation problem as shown in groups I (syphilitic), III (epileptic), VI (somatic) and thereafter very briefly refer to the residue of the delimitation problem. For convenience of reference, a few out-standing remarks concerning the general relations of these divisions to war and peace conditions are inserted here. We dealt in the diagnostic order of exclusion with 190 cases, distributed as in the table below (bear in mind that the method of this book precludes attaching great statistical weight to the comparative figures, since the various authors published their cases for their special rather than their typical interest).

I.Syphilopsychoses34
II.Hypophrenoses (feeble-mindedness and imbecility)18
III.Epileptoses33
VI.Pharmacopsychoses (alcohol; morphine)17
V.Encephalopsychoses (focal brain lesion cases)15[9]
VI.Somatopsychoses29
VII.Geriopsychoses (senile—a null class)0
VIII.Schizophrenoses16
IX.Cyclothymoses7
X.Psychoneuroses12[9]
XI.Psychopathoses15
196

[9] The numbers of focal brain lesion cases and of psychoneuroses must naturally be considered in relation to the great groups of these cases in Sections [B] and [C].

13. The neuropsychiatric side of syphilis in the war is presented in 34 cases (Cases [1 to 34]). The syphilitic basis of sundry military difficulties, quite unsuspected by the laity and probably not too well understood by service men, is suggested by [Case 1], a case of desertion by a French officer of high rank. Nor is [Case 2], in which visions of submarines proved syphilitic, without its warning. Such cases point only too obvious a moral:

14. Neurosyphilitics have no place in the army or navy.

Eight cases ([Cases 3-10]) follow in which the aggravation or acceleration or liberation of neurosyphilis has come about under the conditions of war. Some of these cases suggest the gravity of the problems of compensation, allowance and pension that may arise. We might ask,

15. Should not a government which enlists a syphilitic pay full allowances to him when under war conditions he becomes a neurosyphilitic?

For the government was theoretically able to learn at the start (within a small margin of error by means of the serum test) whether the man was syphilitic. If a one-eyed man loses his remaining eye in an industrial accident in civil life, his damages are often fixed at damages for total blindness; for the industrial firm should not have employed a one-eyed man in an industry dangerous to eyes. The principle cannot differ with a man hired in a spirochete-bearing state: The company has hired a man who may under traumatic conditions become an incompetent neurosyphilitic, and should pay damages accordingly when the aggravation begins.

16. What are the responsibilities of government if the neurosyphilis is due to a syphilis acquired during the war?

Often such infection may be due to a tragical form of “negligence.” But, as pointed out in a work on Neurosyphilis, 1917, I believe that any form of licensing system, official or virtual, which would permit the purchase of syphilis in or near military zones, abolishes the argument of “negligence.” A man acquiring syphilis under the connivance of government ought to stand as well as a syphilitic hired by the government, when it shall come to the question of compensation for incapacity. Yet, it may be argued, the man might have remained continent after all. The point is left to the mercy of jurists.

17. The share of neurosyphilis in the “crimes” and disciplinary problems of the army is intimated in three cases (Cases [11 to 13]).

18. The latter part of the series (Cases [14 to 31]) embraces problems of a more medical nature, touching traumatic paresis and “Shell-shock paresis.” Unusual, these cases may be readily conceded to be; but their infrequency is not such as to put them out of the field of consideration in the “Shell-shock” group.

Very intriguing to the diagnostician would be the cases of pseudotabes and pseudoparesis (Cases [23] and [26] of Pitres and Marchand), were such cases at all frequent.

[Case 28], in which shell-shock (the physical event) apparently caused recurrence of a syphilitic (!) hemiplegia, is particularly instructive and might better belong with the series (under [Section B: Nature and Causes, Cases 286-301]) in which ante-bellum weak spots were picked out by shell-shock and war conditions. But [Case 28] is placed here for its syphilitic interest.

[Case 29] stands out as a warning example not to crowd the hypothesis and try to make syphilis sponsor for everything, even when it plainly is at work.

[Cases 32-34] are cases in which syphilis played a part, though possibly a minor part, in certain peculiar mental reactions.

To sum up the part played by syphilopsychoses and syphiloneuroses in the war, we find, that

19. Syphilis may have occasionally a serious military effect, as in the case of desertion by a French officer of high rank.

20. Important problems of pension, retirement, and compensation are brought out, and as no previous war has had the benefit of the Wassermann reaction and other exact tests bearing upon the nature, progress, and curability of neurosyphilis, we may hope for a far more scientific determination of these questions by review boards during and after the war.

21. We find a few instances in which neurosyphilis has played a part in the discipline of troops. According to one author (Thibierge, 1917), syphilis has become a genuine epidemic among French soldiers and mobilized munition workers. In Germany, also, it may be remembered that Hecht has claimed that no less than an equivalent of sixty army divisions has been temporarily withdrawn from fighting on the Teutonic side for venereal diseases. In this connection, Neisser had recommended the giving of salvarsan and mercury in the trenches. According to Hecht, the appearance of syphilis should be a signal for sending a man to the front. Hecht also made the somewhat bizarre suggestion that special companies of syphilitics should be formed, for convenience of treatment, on the firing line.

22. A more solid foundation is laid for the theory that general paresis may be evoked by trauma—a conclusion already fairly well established by civilian cases, notably those of industrial accident.

23. The question whether shell-shock (the physical event) can produce general paresis is probably to be settled in the affirmative, for it may always prove difficult to show that the physical shell-shock did not actually produce mechanical molar lesions of the brain, permitting the rapid advance of spirochetes. It is perhaps easier to prove that shell explosion may precipitate neurosyphilis in the form of tabes dorsalis (take, for example, Cases [21] and [22]). The cases of most importance in the question of traumatic neurosyphilis and traumatic paresis are cases [20], [21], [22], [24] and [25].

24. The picking out of preëxistent weak spots by Shell-shock is given clear illustration, as in the case of Shell-shock recurrence of an old syphilitic hemiplegia ([Case 28]). Only on such a basis could the syphilitic ocular palsy of [Case 19] be satisfactorily explained.

25. The coexistence of functional phenomena with organic syphilitic phenomena is demonstrated by Cases [29] and [30]; perhaps also in [Case 16].

26. It must be said that presumably there will be, unless our authorities are more successful than in the past, a considerable increase in venereal disease as the result of army life in wartime. There will be a certain number of cases of neurosyphilis a number of years after discharge from the army caused by infection acquired during service. (Germany is said to have got its crop of neurosyphilis after the War of 1870, in the early eighties of the last century.) The names of all soldiers acquiring syphilis and not considered cured at the time of discharge should, under ideal conditions, be given to health organizations in their home states so that they may be accorded proper care and treatment.

27. Shell-shock and epilepsy. The authorities have been somewhat surprised by the number of epileptics that have gotten by the draft boards. The statistics are not yet ripe, but certainly the enlistment of an epileptic is not a rarity. There are some singular instances in the war literature showing how hard it sometimes is to bring out epilepsy. There is the English case, for example, of a man, an epileptic’s son, who had himself been epileptic from 11-18, who entered the Expeditionary Force at the outbreak of hostilities, went through the retreat from Mons and through two years of active warfare without having a single epileptic convulsion. In fact, in September, 1916, he was put in charge of eight men on guard duty. Apparently the new responsibilities worried him, and two months later he had become epileptic to the extent of petit mal.

Another man who had never been epileptic (though his sisters had been) was wounded four times, was never worried by shell fire, got somewhat depressed after the death of his father and five brothers in the service, but did not become epileptic until finally he was blown up and buried three times in one day, and it was a whole month later when he became epileptic, although treatment by rest and bromides apparently resolved the affair.

Other cases seem to show that war experiences can bring out epilepsy, although in most instances it would appear that there was an epileptic or otherwise neuropathic heredity in these cases.

28. There is one author, Ballard, who has actually propounded a theory of Shell-shock as epileptic, pointing out the occurrence of epilepsy long after the early symptoms of Shell-shock have disappeared.[10] There does not appear to have been any increase in epileptics as the result of the war, either from the standpoint of Shell-shock or from the standpoint of brain injury, so far as the records of the National Hospital for the Paralyzed and Epileptic in London are able to show.

[10] In one instance, fugue and other minor symptoms were later replaced by epilepsy; in another, an epileptic confusion developed eight months after an explosion, and in a third, a case of mine explosion, stammering resolved into mutism and mutism finally into epilepsy. Of course there is a so-called general resemblance among all forms of hyperkinesis or irritative discharge of the nervous system. If we term epileptic all the things that various authors have termed epileptoid, we may be doing nothing more than to say that we believe these cases all subject to epileptic hyperkinesis. In that direction, of course, it has long been said that dipsomania was really a form of epilepsy. Whether Shell-shock is ordinarily subject to recurrence in such wise as to imitate the recurrence of attacks of dipsomania, of manic-depressive psychosis or of epilepsy, is, to say the least, doubtful at this time.

29. As in all other instances of mental or nervous disease, when an epileptic returns from the war, whether or not he was potentially or actually an epileptic before the war, his relatives are bound to term him a case of Shell-shock. I am familiar with a case in a hospital in a certain Atlantic port, a case of pronounced and obvious epilepsy. In the wards he is treated as the hero of every occasion. Not only the nurses and attendants, but the other patients and often the physicians can hardly resist thinking of him as somehow a case of Shell-shock. It is a comment upon the status of mental hygiene in general that this self-same epileptic, had there been no war, would have been, as it were, a common or garden epileptic, mute and inglorious on some sunny hillside.

30. In passing I may note how many instances in the medicolegal part of the war literature there are of epileptics who come up for courtmartial or for medical examination pending courtmartial. We may suspect that many a case of epileptic fugue has been regarded as a case of desertion. There is the case of an epileptic who left camp one morning and got drunk. Investigation showed that he left camp before anything epileptoid had happened. He developed in his drunkenness a pretty clearly epileptic crisis with great violence, for which he had a complete loss of memory. The French Council condemned him to five years of labor, not admitting in this instance that responsibility was diminished by reason of the man’s being epileptic. In short, from the military point of view, he should, so to say, have known enough not to have gotten drunk, and so have avoided getting his epileptic crisis. Of course the decision was here very close, and a like decision would not always be rendered. To add to the complication of this particular case, the very first epileptoid crisis which caused it to be known that the man fell into the epileptic group was due to Shell-shock, or at least developed immediately after the bursting of a shell nearby. On the whole, however, the relation between epilepsy and Shell-shock is not a close one.

31. The question of epilepsy in the war is considered in a series of 33 cases ([Cases 53-85]). The considerations range from banal cases developing quite incidentally, up to cases regarded by one author (Ballard) as illustrating a theory of Shell-shock as epileptic ([Cases 82-84]). First are considered two cases actually syphilitic. In the first ([Case 53]), the diagnosis had to be revised from epilepsy to neurosyphilis (the convulsions of this neurosyphilitic were brought out by alcohol, and the reporter, Hewat, remarks that the serum of any patient developing epileptiform seizures between 35 and 50 years of age should be subject to test). In [Case 54], the soldier got his syphilis in wartime and the syphilis acted to bring out an epilepsy with which the patient was hereditarily tainted (epilepsy syphilogenic, i.e., reactive to syphilis).

[Case 55] might perhaps better have been considered in the group of hypophrenoses, as he was epileptic and imbecile. He was at first condemned by court martial to five years’ imprisonment for leaving his post in the presence of the enemy.

Another mixed case is [Case 57], in which another feeble-minded subject showed seizures of a psychogenic nature, which he was able eventually to stop by clenching his teeth.

Seven cases ([Cases 58-64]) are cases of a disciplinary nature, amongst which attention may be called to [Case 62], the “specialist in escapes.” The medicolegal questions of responsibility in the drunken epileptic ([Case 58]) are particularly perplexing.

32. [Case 64] is one of epilepsy following antityphoid inoculation one-half hour. There were five attacks during a fortnight and then no others. The antityphoid inoculation came eight weeks after a shell wound of the thigh, which had not served to bring out the epilepsy in this patient. Bonhoeffer had three other instances of the sort: one in a severely tainted subject, and the others in alcoholics.

33. The next group of cases, [66-77], yields a series of the most interesting medical problems, some of which scarcely belong in an account of psychoses incidental in the war. [Case 66] is one with recovery from Jacksonian seizures after decompression of the upper Rolandic region, which was edematous following an (apparently very slight) scalp wound and shell-shock.

34. The cure by studied neglect (in [Case 67]) is one of hystero-epileptic convulsions occurring in series. [Case 68] demonstrates the superposition of hysterica phenomena over a genuine epilepsy, a case therefore with two diagnoses: not hystero-epilepsy, but epilepsy and hysteria.

35. The theoretical implications of [Case 69] are striking: The case was one of musculo-cutaneous neuritis (gross enlargement), in association with which Brown-Séquard’s epilepsy developed, waxing and waning with the disease of the nerve. Another case of possible reactive epilepsy is [Case 70], and a case of epilepsia tarda brings up the same issue ([Case 71]). [Cases 72-74] are cases with strong psychogenic components, of which [Case 74] is particularly instructive on account of the gradual building up of a remarkable visual aura of an approaching fire-wheel, this aura developing after scotoma from looking at the sun. Cases [75] and [76] are cases of somewhat doubtful epilepsy, one of fugue and the other of a solitary epileptic episode following 38 artillery battles in two months.

36. Friedmann discusses narcoleptic seizures, regarded as due to the brain fag of trench life ([Case 77]). Sham fits and epileptoid attacks controllable by will appear in Cases [78] and [79] respectively. [Case 80] is a striking case of a man with epileptic taint, which two years’ service, four wounds, the death of a father and five brothers, and eventually Shell-shock and burial thrice in one day, served at last to bring out.

37. Shell-shock and bodily disease. In civilian psychopathic hospital practice, if a case is not syphilitic, not feeble-minded, not epileptic, not alcoholic, and without signs of intracranial pressure or disorder of reflexes, then we, as specialists, must consider whether the disease in question is not due to some form of bodily disorder outside the nervous system; for example, we think in practice of infectious psychoses, of exhaustive states such as the puerperium, of toxic states such as may be found in cardiorenal cases, and of glandular phenomena such as we are familiar with in the thyroid disorders.

Under the war conditions, it might be thought that these somatic disorders yielding the so-called symptomatic mental diseases would be frequently found.

Aside from these rarities in puzzling diagnosis, we find more commonly in the literature evidence of

38. The soldier’s heart, the so-called “D.A.H.,” or disordered action of the heart, of the English army reports. This soldier’s heart is sometimes associated with hyperthyroidism, and sometimes hyperthyroidism is found alone, with symptoms suggesting those of a sort of diffuse Shell-shock.

One author claims rapid cures of hyperthyroidism by the relatively simple process of hypnosis. Perhaps this is not too unlikely in view of the still obscure relations between mind and hormones. A little more surprising, perhaps, is the assertion met with that psoriasis is sometimes a Shell-shock phenomenon.

The literature clearly shows, however, that, as in most special problems, the internist is still in demand. I recall how one internist was misled on the witness stand into stating that he was a “general specialist.” This is what we would all need to be, were we to solve the problems of Shell-shock in the time allotted to us by the war.

39. Following are special cases to show how near the somatic (“symptomatic”) may be to Shell-shock.

The somatic group of psychoses, sometimes termed symptomatic, is illustrated in 29 cases ([Cases 118-146]), and comprises cases ranging all the way from rabic phenomena to those of hyperthyroidism. Possibly the first two cases (Cases [118] and [119]) might better be placed among the encephalopsychoses. [Case 118], one of rabies, was that of a farmer without history of having been bitten by a dog, who eventually came to autopsy and received the Pasteur Institute diagnosis of rabies. A diagnosis of angina was at first made. When the symptoms became more serious and masseter spasm developed, a question of tetanus arose. Later the diagnosis of meningitis was suggested. At this point, the symptoms became predominantly psychotic.

[Case 119] was one of seven cases reported by Lumière and Astier, in which delirium and hallucinations appeared as a complication of tetanus. The case in question had been given anti-tetanic serum. (Another case showed identical symptoms without having been given anti-tetanic serum.)

That a local tetanus could be mistaken for hysteria might seem à priori unlikely, but Cases [120] and [121] indicate as much; and [Case 121] is interesting on account of the officer’s own description of his local tetanus and its treatment. A psychosis apparently related with dysentery occurred in [Case 122]. Hysteria followed typhoid fever in [Case 123]. Another form of typhoid fever complication is perhaps shown in [Case 124], wherein the diagnostic question lay between dementia praecox and a post-typhoid encephalitis.

Paratyphoid fever has diagnostic complications, as shown in Cases [125] and [126], wherein the mental symptoms outlasted the fever ([Case 125]), and psychopathic taint was brought out ([Case 126]).

Diphtheria was also represented in the matter of nervous and mental symptoms in Cases [127] and [128]. In [Case 127] the nervous symptoms appeared eight days after evacuation for diphtheria. There were a few sensory symptoms (hypalgesia, hypoacusia, and peculiar bone sensations) in this subject. The phenomenon in [Case 128] was apparently one of hysterical paraparesis; nor does it appear in this case that the hysterical paralysis was preceded by polyneuritis.

Malarial effects are present in three cases ([Cases 129-131]), of which [Case 129] showed an amnesia, [Case 130] a Korsakow syndrome, and [Case 131] anterior horn symptoms. [Case 132] exemplifies 15 instances of acroparesthetic disorders in so-called trench foot. This case, like several others, is inserted in this group, not because the symptoms are psychotic, but because they might cause diagnostic difficulty as against hysterical phenomena.

[Case 133] is an autopsied case of bronchopneumonia following bullet injury of the spine. Microscopic examination of the spinal cord showed small cavities in the first and fourth dorsal segments. This myelomalacia was doubtless related with the bullet injury of the spine, although the spinal cord was not itself directly touched by the bullet. [Case 134] might be regarded perhaps as one of Shell-shock and should be considered in relation with [the cases at the head of Section B (Cases 197-209)]. The case might be regarded as functional, except for a decubitus that developed. Despite this decubitus, there was recovery. The case is placed in the somatic group on account of pulmonary phenomena which it seemed well to relate with those of [Case 133]. Compare also [Case 136], in which reflex phenomena are associated with a bullet wound of the pleura. [Case 135] is a many-sided case, with ante-bellum hysteria and certain Shell-shock phenomena. While under observation, the patient caught typhoid fever and then developed neuritis. This neuritis was very probably not post-typhoidal so much as hysterical. Accordingly, the case should be considered in connection with the ante-bellum weak spot series, [Section B (Cases 286-301)]. There was in this case a cure by reëducation.

The reflex hemiplegia with double ulnar syndrome in [Case 136] seemed to have followed a bullet wound of the pleura. According to the authors, Phocas and Gutmann, there is considerable literature upon nerve complications of pleura trauma, including syncope, epilepsy, and (more rarely) hemiplegia.

Heart cases are illustrated by [Cases 137-139]: the first one of hysterical tachypnoea, and the others of the so-called soldiers’ heart.

Diabetes mellitus seems to have followed war strain and shell wound in [Case 140].

It is doubtful whether shell-shock and burial had anything to do with the appearance ten days later of lipomata, which proved to be the initial phenomenon in a pronounced Dercum’s disease. ([Case 141]).

Hyperthyroidism is illustrated in four cases ([Cases 142-144]). The first ([Case 142]) appears to have been cured by inducing deep somnambulism (Tombleson claims cures by suggestion in eight cases of hyperthyroidism). Neurasthenia or questionable Graves’ disease ([Case 145]) followed Shell-shock. That of [Case 144] followed 10 months’ service, at times under protracted shell fire. A forme fruste of Graves’ disease is shown in [Case 145], in which the phenomena followed gassing and shelling.

A somewhat curious somatic complication in a case of Shell-shock hysteria was the finding of a needle in the left upper arm, which was then extracted. ([Case 146]).